NPIMap

Individual provider Active NPI

Paul Ryan Lane, PA-C

  • Physician Assistant
  • Mount Vernon, IL
National Provider Identifier
1962023820
Registry record updated Dec 18, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
085.007905 Issued in IL
Practice address
4101 N Water Tower PL
Mount Vernon, IL 62864-6296
Phone
(618) 244-6222
Fax
(618) 246-1247
NPI assigned
May 1, 2020
Last updated
Dec 18, 2020By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Dec 18, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician AssistantGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363A00000X 085.007905 IL Primary

Addresses

Primary practice location

4101 N Water Tower PL
Mount Vernon, IL 62864-6296

Mailing address

4101 N Water Tower PL
Mount Vernon, IL 62864-6296
Phone (618) 244-6222

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20200929001344 IL Practitioner - Physician Assistant 3870912611 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2020
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

1209 W Robinson St
Wayne City, IL 62895-9672
Phone (618) 895-2050

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
085.007905ILMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Deaconess Illinois Crossroads Inc Single Specialty PastSince Dec 6, 2022 Accepting new patients

Interoperability endpoints

  • Direct secure messaging: paul.lane.1@27782.direct.athenahealth.com
  • Direct secure messaging: plane422451@direct.deaconess.com

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 8

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1588291200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1608249600000",
    "number": "1962023820",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4101 N WATER TOWER PL",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628646296",
            "telephone_number": "618-244-6222",
            "fax_number": "618-246-1247"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4101 N WATER TOWER PL",
            "city": "MOUNT VERNON",
            "state": "IL",
            "postal_code": "628646296",
            "telephone_number": "618-244-6222",
            "fax_number": "618-246-1247"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LANE",
        "first_name": "PAUL",
        "middle_name": "RYAN",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-05-01",
        "last_updated": "2020-12-18",
        "certification_date": "2020-11-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "IL",
            "license": "085.007905",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Mount Vernon, IL

Sources for this page

Verify at the official NPI Registry.